Name *
Sex *
Have you ever had any injury, illness, back or joint condition that you may feel could be aggravated by exercise? *
Have you ever suffered from Asthma, Diabetes, Epilepsy, Hernia, Dizziness, Circulation problems, Arthritis or an Ulcer? *
Have you ever had a Heart Condition, Stroke, Palpitations, Murmers or pains in the chest? *
Have either of your parents or brother/sister had any heart problems prior to the age of 60? *
Are you pregnant or recently given birth? *
Do you currently participate in regular exercise? *